Clinical Characteristics and Prognostic Factors of Scleral Rupture Due To

Home , Hyphema, Pars plana

1 2 1 3 1 LNCLSTUDY CLINICAL Clinical characteristics OE Yucel , S Demir , L Niyaz , O Sayin ,AGul and N Ariturk1 and prognostic factors of scleral rupture due to blunt ocular trauma

Abstract Purpose To describe and identify ocular and Eye (2016) 30, 1606–1613; doi:10.1038/eye.2016.194; wound characteristics, and prognostic factors published online 2 September 2016 associated with final visual acuity (VA) in patients with scleral rupture due to blunt Introduction ocular trauma. Methods The medical records of 61 patients Open globe injuries (OGIs) are a major cause of with globe rupture due to blunt ocular visual loss and blindness. The mean estimated trauma who underwent primary repair were incidence of OGIs is ~ 3.5 cases in 100 000 reviewed retrospectively. The data recorded annually, leading to 200 000 OGIs per year included demographic characteristics, initial worldwide.1 A globe rupture is a type of OGI and final VA, ocular signs, wound caused by blunt ocular trauma and has poor characteristics, and surgeries. Initial VA, visual outcome.2 ocular signs, wound characteristics, and Several studies have suggested that the factors surgeries were analyzed to determine the that significantly predict visual outcome after fi – association with the nal VA. OGIs are presenting visual acuity (VA),3 6 Results Forty three women and 18 men with presence of a relative afferent pupillary defect a mean age of 43.6 ± 23.5 years were included 3,7–9 4,6,7,10,11 1Department of (RAPD), mechanism of injury, – Ophthalmology, Medical in the study. The locations of scleral wounds wound location,8,10,12 14 wound size and Faculty, Ondokuz Mayis were mostly in the superonasal quadrant extension,10,11,15,16 adnexal trauma,7,9,12,17 lens University, Samsun, Turkey (41.0%) and zone 2 (75.4%). In eyes with damage,4,11 hyphema,3,11 vitreous hyphema (P = 0.009), vitreous hemorrhage hemorrhage,3,4,8,10,12 and retinal 2Department of (P = 0.001), and retinal detachment (P = 0.004), detachment.4,5,7,12,17 Ophthalmology, Medical final VA was statistically worse than eyes Faculty, Gaziosmanpasa The major signs of scleral rupture are VA with without these signs. A moderate positive University, Tokat, Turkey light perception or less, conjunctival edema and correlation was found between the initial and subconjunctival hemorrhage, hyphema, ocular 3Clinic of ophthalmology, final VA (Po0.001). Final VA was statistically hypotony, impairment or dislocation of the lens, Develi Hatice Muammer worse in eyes with horizontal midline vitreous hemorrhage, and retinal Kocaturk State Hospital, wounds than in eyes with vertical midline detachment.15,16,18 To our knowledge, there are Kayseri, Turkey wounds (P = 0.002). A moderate negative correlation was found between scleral wound not enough studies on the clinical characteristics Correspondence: fi length and final VA (Po0.001). Patients who and their effects on nal VA in eyes with scleral OE Yucel, Ondokuz Mayis rupture. Russell et al determined that an initial University, Medical Faculty, underwent cataract surgery had statistically Department of better final VA (P = 0.002). VA of 5/200 or beter, absence of scleral rupture, Ophthalmology, Atakum Conclusions Scleral rupture was detected and a rupture length of less than 11 mm were 55139, Samsun, Turkey mostly in females, superonasal quadrant and prognostic factors of ambulatory vision for eyes Tel: +903623121919/ zone 2. Poor final VA was significantly with ruptured and intact globes after blunt 905057191071; 15 Fax: +903624576041. associated with poor initial VA, longer trauma. The absence of a hyphema and the E-mail: drozlem38@hotmail. wound length, horizontal midline wound, presence of a rupture of 9 mm or less were com presence of hyphema, vitreous hemorrhage reported as good prognostic signs.16 and retinal detachment at presentation, and In the present study, we aimed to describe and Received: 27 January 2016 cataract surgery not performed during follow- identify ocular and wound characteristics and Accepted in revised form: fi 11 July 2016 up period. Scleral ruptures have different prognostic factors associated with nal VA in Published online: demographic, ocular and wound patients with scleral rupture due to blunt ocular 2 September 2016 characteristics than other open globe injuries. trauma. Characteristics of scleral rupture OE Yucel et al 1607

Materials and methods performance of vitrectomy and cataract surgery during follow-up period. The medical records of patients with OGIs who The statistical analysis was performed using V21 IBM underwent primary repair between January 2008 and SPSS (SPSS Inc., Chicago, IL, USA). The Shapiro-Wilk test December 2013 were reviewed retrospectively. Sixty one was used as a normality test for the quantitative data. The eyes of 61 patients with scleral rupture due to blunt ocular Kruskal–Wallis and Mann-Whitney U tests were used to trauma were included in the study. This study was compare non-normally distributed data. The Mann– approved by the local research ethics committee. Whitney U-test with Bonferroni correction was used to The data recorded included demographic determine the source of the differences seen in the fi characteristics, initial and nal VA, ocular signs Kruskal-Wallis test. The χ2-test was used to compare (hyphema, endophthalmitis, uveal tissue prolapse or categorical data. The relationships between variables damage, dislocation of the lens, phacocele, traumatic were analyzed with Spearman’s correlation. The results cataract, vitreous hemorrhage, and retinal detachment), were presented as median (min-max), frequency wound characteristics (location, direction, and length), (percent), and mean ± SD. A P-value of o0.05 was and surgeries. considered statistically significant. A P-value of o0.003 The type and zone of injury were defined according to was considered statistically significant for the Mann– the classification system of the Ocular Trauma Whitney U-test with Bonferroni correction. Classification Group.2 Globe rupture was defined as a full thickness wound of the eye wall involving the sclera with Results or without the cornea due to blunt ocular trauma. The location of injury was defined as zone 1 (wound Sixty one eyes of 61 patients with scleral rupture due to involvement limited to the cornea, including corneoscleral blunt ocular trauma were included in the study. Forty- limbus), zone 2 (wound involving 5 mm of sclera from the three (70.5%) were women, and 18 (29.5%) were men. The ± – corneoscleral limbus), or zone 3 (wound involving the mean age was 43.6 23.5 (5 80) years. The mean follow ± – sclera posterior to the 5 mm from the corneoscleral up period was 11.5 9.4 (6 36) months. limbus). Zone 1 injuries were excluded from the study Slit-lamp biomicroscopic examination revealed because of the absence of scleral wound. The location of subconjunctival hemorrhage (61/61, 100%), hyphema injury was additionally defined as superonasal quadrant, (58/61, 95.1%), dislocation of the lens or phacocele inferonasal quadrant, superotemporal quadrant, (13/61, 20.6%), and uveal tissue prolapse or damage (32/61, 52.4%) at presentation. The hyphema was partial inferotemporal quadrant, horizontal midline, and vertical in 24 (39.3%) and total in 34 (55.7%) of 61 eyes. Relative midline. According to the direction to the limbus, the afferent pupillary defect could not be assessed because of wound was defined as parallel, perpendicular or angled, the dense or full hyphema in these eyes. X-ray computed or both. Location and direction of the scleral rupture are tomography (CT) was performed on all patients before illustrated in Figure 1. The lengths of scleral and corneal the operation. B-scan ultrasonography was done in all wounds were recorded from charts of the globe repair. cases after the primary operation. Vitreous hemorrhage In this study, presenting and final VA were grouped was detected in 43 (70.5%) of 61 eyes, and retinal (1 through 5) as no light perception (NLP), light detachment was detected in 25 (40.9%) of 61 eyes by perception (LP)/hand motion (HM), 1/200 to 19/200, ultrasonography. None of the eyes had an intraocular ≥ 20/200 to 20/50, and 20/40, similar to the Ocular foreign body. There were no cases of acute 19 Trauma Score study group. endophthalmitis. The clinical characteristics of the In addition to the zone 1 injuries, penetrating and patients can be seen in Table 1. perforating injuries, cases with missing records and those Initial VA ranged from NLP (n = 20, 32.8%) to 20/60 with a follow-up period of less than 6 months were (n = 1, 1.6%). Final VA ranged from NLP (n = 26, 42.6%) excluded from the study. to 20/20 (n = 3, 4.9%). The distribution of initial and final VA can be seen in Table 1. Statistical methods There were 46 (75.4%) zone 2 and 25 (24.6) zone 3 injuries. Scleral rupture was present in the right eye in The following variables were analyzed to determine the 28 (45.9%) of 61 cases and in the left eye in 33 (54.1%) of association with final VA: initial VA, wound length, 61 cases. The locations of scleral wounds were mostly in wound location, wound direction, presence of corneal the superonasal quadrant (25/61, 41.0%); other locations wound, dislocation of lens or phacocele, uveal tissue can be seen in Table 1. The wound was parallel in 27 prolapse or damage, hyphema, vitreous hemorrhage and (44.3%) cases, perpendicular or angled in 28 (45.9%), and retinal detachment at presentation, traumatic cataract, both in 6 (9.8%) of 61 eyes. There was a corneal

Eye Characteristics of scleral rupture OE Yucel et al 1608

Figure 1 Location and direction of the scleral rupture are illustrated on the right eye.

involvement of wound in 24 (39.3%) of 61 eyes. Sixteen between the initial and final VA (Correlation (34.8%) eyes with zone 2 and 8 (%53.3) eyes with zone 3 Coefficient = 0.588, Po0.001), as seen in Table 1. injuries had corneal involvement. The lengths of scleral Final VA was statistically worse in eyes with horizontal and total (sclera+cornea) wounds were 9.04 ± 5.9 and midline wounds than in eyes with vertical midline 12.42 ± 5.7 mm, respectively. wounds (P = 0.002). There were no significant associations All the eyes underwent primary globe repair. The mean between other wound locations and final VA. An time duration between injury and primary globe repair association between zone of injury, wound direction, was 6.85 ± 3.3 (3–16) h. None of the eyes were primarily corneal wound presence and final VA was not detected, eviscerated or enucleated. Eleven (18.0%) of 61 eyes as seen in Table 1. A moderate negative correlation was underwent secondary evisceration due to painful blind found between scleral, total wound lengths and final eye. Sixteen (26.2%) of 61 eyes underwent cataract VA (Correlation Coefficient = − 0.496 and − 0.417, and surgery, and 8 (13.1%) of 61 eyes underwent vitreoretinal Po0.001 and P = 0.001, respectively). surgery after primary globe repair. There was no significant association between between The rate of phthisical eye was 24.6% (15/61) during the final VA and time duration between injury and primary follow up period. The hyphema was partial in 13.3% globe repair (P = 0.383). In eyes that underwent cataract (2/15) and total in 86.7% (13/15) of phthisical eyes. surgery, final VA was statistically better (P = 0.002), but Vitreous hemorrhage and retinal detachment were an association between vitreoretinal surgery and final detected in 100% (15/15) and 86.7% (13/15) of phthisical VA was not detected, as seen in Table 1. eyes, respectively. Initial VA was NLP in 66.7% (10/15) Total hyphema (P = 0.01), vitreous hemorrhage and LP/HM in 33.3% (5/15) of phthisical eyes. (P = 0.01), retinal detachment (P = 0.001), and initial VA of NLP (P = 0.007) were factors predictive of phthisical eyes. Visual outcome An association between phthisical eyes and other ocular and wound characteristics was not detected. The initial clinical signs were analyzed to determine which factors were associated with poor final VA. Discussion In eyes with hyphema (P = 0.009), vitreous hemorrhage (P = 0.001), and retinal detachment (P = 0.004), final VA Numerous studies have been published to correlate final was statistically worse than eyes without these signs. An visual outcome with several factors related to OGIs. association between uveal tissue prolapse or damage, To our knowledge, there are not enough studies on the dislocation of the lens or phacocele and final VA was not clinical characteristics and their effects on final VA in eyes detected. A moderate positive correlation was found with scleral rupture. This study identified associations

Eye Characteristics of scleral rupture OE Yucel et al 1609

Table 1 Clinical characteristics and visual prognosis of patients with scleral rupture (n = 61)

Variable Final visual acuity Total P

NLP LP/HM 1/200-19/200 20/200-20/50 ≥ 20/40

Gender Female 18 11 3 5 6 43 0.885 Male 7 5 2 1 3 18

Eye Right 16 5 2 3 2 28 0.112 Left 9 11 3 3 7 33

Zone of injury Zone 1 15 14 3 6 8 46 0.213 Zone 2 10 2 2 0 1 15

Location of injury Superonasal 3 4 0 1 1 9 0.005a Superotemporal 1 4 1 0 1 7 Inferonasal 11 5 2 4 3 25 Inferotemporal 3 1 1 0 0 5 Horizontal midline 1 0 0 1 4 6 Vertical midline 6 2 1 0 0 9

Direction of injury Parallel 10 9 1 4 3 27 0.782 Perpendicular or angled 10 7 4 2 5 28 Both of them 5 0 0 0 1 6

Corneal involvement Yes 9 6 2 2 5 24 0.541 No 16 10 3 4 4 37

Hyphema Total 20 9 1 1 3 34 0.009a Partial 4 7 3 5 5 24 No 1 0 1 0 1 3

Dislocation of the lens or phacocele Yes 4 4 1 4 0 13 0.830 No 21 12 4 2 9 48

Uveal tissue prolapse or damage Yes 16 8 3 2 3 32 0.164 No 9 8 2 4 6 29

Vitreous hemorrhage Yes 25 10 2 2 4 43 0.001a No 0 6 3 4 5 18

Retinal detachment Yes 19 2 3 0 1 25 0.004a No 6 14 2 6 8 36

Cataract surgery Yes 0 5 2 5 4 16 0.002a No 25 11 3 1 5 45

Vitreoretinal surgery Yes 0 3 2 1 2 8 0.349 No 25 13 3 5 7 53

Eye Characteristics of scleral rupture OE Yucel et al 1610

Table 1 (Continued )

Variable Final visual acuity Total P

NLP LP/HM 1/200-19/200 20/200-20/50 ≥ 20/40

Initial visual acuity NLP 18 0 0 0 1 19 ˂0.001a LP/HM 7 16 5 5 5 38 1/200-19/200 0 0 0 1 2 3 20/200-20/50 0 0 0 0 1 1 ≥ 20/40 0 0 0 0 0 0

Abbreviations: HM, hand motion; LP, light perception; NLP, no light perception. aStatistically signiﬁcant result.

between wound and ocular characteristics, surgeries and 20.1 to 100% in severe OGIs in the literature.5,7,8,10,13,14 final VA in patients with scleral rupture due to blunt Hyphema was a prognostic factor for poor final VA ocular trauma. (P = 0.009) in our study. Rofail et al3 reported hyphema Open globe injuries occur most frequently in was a predictor of poorer visual outcome. Although, in – males.3,5 9,12 In contrast to the literature, a significant some studies, multiple regression analysis demonstrated female predominance was found in our scleral rupture that there was no correlation between hyphema and series. Emami–Naeini et al14 reported a female final VA.5,7 predominance in fall-related OGIs. In addition, in their Dislocation of the lens or phacocele was seen in 20.6% series, the most common type of injury was rupture of patients. Sixteen (26.2%) patients underwent cataract (90%). Because of this; we proposed that globe rupture surgery. In the literature, there are studies that have may affect female patients more. Our hospital is a reported similar rates of lens injury and traumatic regional hospital that serves both rural and urban areas. cataract8,17 and studies that have reported higher rates of In this region, women also take an active role in working lens injury and traumatic cataract.4,6,12 Patients who life. Especially, in rural areas, women are working in the underwent cataract surgery had statistically better final fields and farming. Therefore, women are more exposed VA (P = 0.002) in our study. Al-Mezaine et al4 said that to work accidents. Open globe injuries can be observed in poor final visual outcome was associated with cataract all age groups, especially between 30 and 50 years surgery if it was not performed during the follow-up old.3,5,7,9,11,12 In our study, the mean age was 43.6 ± 23.5 period. In contrast, some studies detected no association (5–80) years, and this is similar to previous reports. between lens injury or traumatic cataract and visual The rates of patients with VA of NLP were 32.8 and outcome.6,8,12 42.6% at initial and final visits. Bi et al reported the rates Uveal tissue prolapse or damage was seen in 52.4% of of patients with VA of NLP and o0.1 were 30.7% and patients. In contrast to the results of some studies, uveal 100%, respectively, at initial presentation in their ruptured tissue prolapse or damage was not a predictor of visual globe injury series. The ratio of better VA (better than 0.1) outcome in our series. In the series by Rofail et al,3 iris increased from 0 preoperatively to 16.0% postoperatively, prolapse occurred in 47.6% of patients, and it was a and VA improved in approximately half of the patients.20 predictor of poor visual outcome. Likewise, in the series We found a moderate-positive correlation between the by Yalcin Tök et al,5 uveal tissue prolapse occurred in initial and final VA. Poor initial VA was a strong 21.7% of patients, and it adversely affected final VA. predictor of poor visual outcome (Po0.001). Visual Bi et al reported choroidal injuries in 62.7% of patients acuity changed from NLP to 20/32 in only one patient with ruptured globe injuries. They said that choroidal (1/19, 5.2%). In 7 patients (7/42, 16.7%), VA changed injury could result in severe hemorrhage, scarring, and from LP or better to NLP. Visual recovery rate from NLP proliferation.20 We did not use ultrasound biomicroscope to LP or better for OGIs varies in the literature; Agrawal to determine ciliary or choroidal injuries. We detected et al, Salehi-Had et al, and Soni et al reported it in 33.3%, high rates of vitreous hemorrhage and VA of NLP. This 26.1%, and 23% of their patients, respectively.8,21,13 could be a result of ciliary or choroidal injuries. The rate of Feng et al reported a 54.5% visual recovery rate in patients vitreous hemorrhage was 70.5% in our series. Similar to who underwent vitreoretinal surgery.10 the results of many studies, vitreous hemorrhage was a In our series, hyphema was seen in 95.1% of patients. prognostic factor for poor final VA (P = 0.001). In the Russel et al15 reported that the rate of hyphema was 78.9% study by Rofail et al,3 vitreous hemorrhage was seen in in eyes with occult ruptures. This rate was reported to be 40.6% of patients and was reported as a predictor of poor

Eye Characteristics of scleral rupture OE Yucel et al 1611

visual outcome. In the study by Al-Mezaine et al4 in fall-related OGIs in which rupture is the most common vitreous hemorrhage was seen in a small number of type of injury (90%).14 patients (6.5%), but it had a significant association with In our study, all injuries were zone 2 and 3 injuries. final visual outcome. The rate of vitreous hemorrhage was In contrast to most previous reports, there was not a 77.8% in eyes with NLP in the study by Agrawal et al. significant association between zone of injury and final They found an association between vitreous hemorrhage VA in our study. These studies reported that final visual and poor postoperative outcome.8 However, some studies outcomes were significantly correlated with the zone of found no association between vitreous hemorrhage and injury. Greater posterior wound extension leads to poorer visual outcome.6,13,14 Feng et al10 considered that severe final outcomes, and eyes with zone 3 injuries were more intraocular hemorrhage was not only a predictor of an statistically associated with poor VA.2,4,6,8,10 Yalcin Tok unfavorable outcome, but also a reflection of the et al5 found that the risk of having a final VA worse than seriousness of the ocular damage, which includes severe 20/200 was three times higher in zone2 injuries and intraocular tissue injury, such as to the choroid and retina. 5.5 times higher in zone 3 injuries when compared with In our study, retinal detachment was detected in 40.9% zone 1 injuries. Posterior segment injury can cause of patients. Retinal detachment was a prognostic factor irreversible damage to the retina and optic nerve and thus for poor final VA (P = 0.004). In the study by Feng et al10 has a poor visual prognosis. In the study by Al-Mezaine retinal detachment was seen in 51.5% of patients whose et al4 OGIs involving zones 2 and 3 resulted in vision was NLP, and it was a prognostic factor for significantly higher rates of retinal detachments and outcome. There are studies reporting lower retinal phthisis than those involving zone 1. In the study by detachment rates and significant association between Agrawal et al cases with zone 3 injuries not extending retinal detachment and final VA.4,5,7 Conversely, some beyond ‘annulus of Zinn’ were associated with good studies reported that retinal detachment was not a outcomes. The possible explanation for adverse outcomes predictor of outcome.6,8,13,14 in injuries extending beyond ‘annulus of Zinn’ is An association between vitreoretinal surgery and final significant vitreo-retinal trauma associated with VA was not detected in our study. Al-Mezaine et al posteriorly extending scleral laceration. They said that reported that performance of pars plana vitrectomy was a based on the justification given by Ocular Trauma significant negative predictor for good final VA but was a Classification Group, they have arbitrarily taken it as significant positive predictor for an intermediate visual 5 mm as injuries in that zone may not extend into pars outcome.4 Emami-Naeini et al14 suggested PPV had a role plana.11 We did not evaluate the relationship between in preventing and/or diminishing the risk of developing visual outcome and extent of wound according to the NLP in posterior segment complications associated with rectus muscle insertion. fall-related OGIs. Feng et al10 said that traumatized eyes The locations of scleral wounds were mostly in the with NLP can be anatomically restored with LP or better superonasal quadrant (41.0%) in our study. Russel et al vision if vitreoretinal surgery is attempted. Russell et al15 found that the rupture occurred superiorly in 18 of 22 said that the vitrectomized eyes had a better result, eyes with severe blunt ocular trauma. They reported that suggesting that early pars plana vitrectomy is of benefitin rupture was detected mostly in the superotemporal selected rupture cases. quadrant.15 In Cherry’s report, 33 of the 41 anterior Eleven (18.0%) eyes underwent secondary evisceration ruptures were located in the superior half of the eye. in our series. The rate of evisceration–enucleation was The nasal-superior quadrant between the limbus and compatible with some studies3,9,12,17 but was lower than spiral of Tillaux, the temporo-superior quadrant between the 53% in the study of Soni et al However, in their study, the spiral of Tillaux and 5 mm posterior to the equator, all eyes had NLP of VA.13 and the temporosuperior quadrant between the limbus There was no case of acute endophthalmitis in our and spiral of Tillaux were the three most common areas study. The incidence of post traumatic endophthalmitis involved, in decreasing order of frequency.16 Most of the varied from 1.2 to 30% in previous OGI series.5,14,17,22 scleral ruptures involved the superior hemisphere of the The risk factors for endophthalmitis are presence of globe. We detected worse final VA in eyes with horizontal intraocular foreign body, trauma in a rural environment, midline wound than in eyes with vertical midline wound delayed primary surgery, delayed systemic antibiotic (P = 0.002) and no significant associations with other treatment for 424 h, lens disruption, low age, low visual wound locations and final VA. This might be explained acuity at presentation, and long duration of hospital stay by the rupture of long ciliary arteries and nerves, which – in OGIs.22 24 Thompson et al23 reported that may increase hemorrhage and delay or deteriorate wound endophthalmitis did not occur in eyes with blunt ocular healing. injury, which is similar to our results. Emami-Naeini et al According to the direction to the limbus, the wound reported an extremely low rate of endophthalmitis (1.2%) was parallel in 44.3%, perpendicular or angled in 45.9%,

Eye Characteristics of scleral rupture OE Yucel et al 1612

and both in 9.8% of eyes. There was not a significant and final VA. Scleral ruptures have different association between wound direction and final VA in our demographic, ocular and wound characteristics than study. Russel et al15 found circumferentially oriented other OGIs. The careful assessment of prognostic factors rupture in 36%, radially oriented rupture in 28%, and of the scleral rupture due to blunt ocular trauma allows both circumferentially and radially oriented rupture in realistic expectations of final visual outcome by doctors 36% of 25 patients. Agrawal et al reported that length of and patients. laceration or radial extent of scleral wound significantly affected the final vision outcome in zone 3 penetrating or blunt injuries. They thought that the radial scleral Summary lacerations extending beyond rectus insertions were often What was known before associated with poorer outcome because of co-morbid K Numerous studies have suggested that the factors that fi factors such as retinal detachment, vitreous traction, and signi cantly predict visual outcome after OGIs are presenting VA, presence of a relative afferent pupillary significant vitreous loss.11 To our knowledge, there are no defect, mechanism of injury, wound location, wound size studies in the literature about wound location and and extension, adnexal trauma, lens damage, hyphema, direction and their effects on final VA in the scleral vitreous hemorrhage, and retinal detachment. rupture due to blunt ocular trauma. K OGIs occur most frequently in males. There was a corneal involvement of wound in 39.3% of K Ruptures are located in the superior half of the eye. eyes in our study. There was no significant association K To our knowledge, there are no studies in the literature fi between presence of corneal wound and final VA. Lee about wound characteristics and their effects on nal VA in the scleral rupture due to blunt ocular trauma. et al reported that cornea wound across the pupil was a poor prognostic factor. They thought that the central What this study adds location and irregularity of the corneal wound, instead of K This study has identified associations between wound and the length, would result in scarring and significant ocular characteristics, surgeries and final VA in patients astigmatism and correlate with an unfavorable outcome. with scleral rupture due to blunt ocular trauma. But in their study, penetrating injuries were the major K Scleral upture was detected mostly in females, superonasal type of injury.25 quadrant and zone 2. K fi fi A moderate negative correlation was found between Poor nal VA was signi cantly associated with poor initial fi 15 VA, longer wound length, horizontal midline wound, wound length and nal VA in this study. Russel et al presence of hyphema, vitreous hemorrhage and retinal fi reported that nal VA correlated inversely to the length of detachment at presentation, and cataract surgery not the rupture. Feng et al and Cherry detected that wound performed during follow-up period. length of 9 mm or less was associated with good visual K A moderate positive correlation was found between the fi outcome and that wound length of ≥ 10 mm was initial and nal VA and moderate negative correlation was fi associated with poor visual outcome.10,16 Al-Mezaine et al found between wound length and nal VA. detected that wound length of 10 mm or less was associated with good visual outcome and that wound fl length of 410 mm was associated with poor visual Con ict of interest outcome.4 Pieramici et al said that larger wounds tend to The authors declare no conflict of interest. involve more posterior structures and the prognostic implication of wound length is probably the posterior extent of the injury. As such, they felt that the Acknowledgements identification of wound location was the more important We thank Naci Murat (Statistician. Assistant Professor. factor and that additionally reporting wound length Department of Industrial Engineering, Faculty of 2 would be redundant. But, some ruptures are parallel to Engineering, Ondokuz Mayis University, Samsun, the corneoscleral limbus and not extent to the posterior of Turkey) for assistance in clinical information analysis. the globe. In this study, rupture was detected mostly in females, superonasal quadrant and zone 2. Poor final VA was significantly associated with poor initial VA, longer References wound length, horizontal midline wound, presence of hyphema, vitreous hemorrhage and retinal detachment at 1 Negrel AD, Thylefors B. The global impact of eye injuries. – presentation, and cataract surgery not performed during Ophthalmic Epidemiol 1998; 5: 143 169. 2 Pieramici D, Sternberg P, Aaberg TM, Bridges WZ, Capone A, follow-up period. A moderate positive correlation was Cardillo JA et al. A system for classifying mechanical injuries fi found between initial and nal VA, and a moderate of the eye (globe). The Ocular Trauma Classification Group. negative correlation was found between wound lengths Am J Ophthalmol 1997; 123:820–831.

Eye Characteristics of scleral rupture OE Yucel et al 1613

3 Rofail M, Lee GA, O'Rourke P. Prognostic indicators for open indicators of fall-related open globe injuries. Retina 2013; 33 globe injury. Clin Experiment Ophthalmol 2006; 34(8): 783–786. (10): 2075–2079. 4 Al-Mezaine HS, Osman EA, Kangave D, Abu El-Asrar AM. 15 Russell SR, Olsen KR, Folk JC. Predictors of scleral rupture Prognostic factors after repair of open globe injuries. and the role of vitrectomy in severe blunt ocular trauma. J Trauma 2010; 69(4): 943–947. Am J Ophthalmol 1988; 105(3): 253–257. 5 Yalcin Tök O, Tok L, Eraslan E, Ozkaya D, Ornek F, Bardak Y. 16 Cherry PM. Indirect traumatic rupture of the globe. Arch Prognostic factors influencing finalvisualacuityinopenglobe Ophthalmol 1978; 96: 252–256. injuries. JTrauma2011; 71(6): 1794–1800. 17 Knyazer B, Bilenko N, Levy J, Lifshitz T, Belfair N, 6 Agrawal R, Rao G, Naigaonkar R, Ou X, Desai S. Prognostic Klemperer I et al. Open globe eye injury characteristics and factors for vision outcome after surgical repair of open globe prognostic factors in southern Israel: a retrospective – injuries. Indian J Ophthalmol 2011; 59(6): 465 470. epidemiologic review of 10 years experience. Isr Med Assoc J 7 Rahman I, Maino A, Devadason D, Leatherbarrow B. Open 2013; 15(3): 158–162. globe injuries: factors predictive of poor outcome. Eye 2006; 18 Wang YS, Xu JF, Guo CM. Clinical characteristics of occult – 20(12): 1336 1341. Zhonghua Yan Ke Za Zhi 44 – fi scleral rupture. 2008; (5): 431 435. 8 Agrawal R, Wei HS, Teoh S. Predictive factors for nal 19 Kuhn F, Maisiak R, Mann L, Mester V, Morris R, outcome of severely traumatized eyes with no light Witherspoon CD. The ocular trauma score (OTS). Ophthalmol perception. BMC Ophthalmol 2012; 12: 16. Clin North Am 2002; 15: 163–165, vi. 9 Yu Wai Man C, Steel D. Visual outcome after open globe 20 Bi H, Cui Y, Li Y, Wang X, Zhang J. Clinical characteristics injury: a comparison of two prognostic models - the ocular and surgical problems of ruptured globe injury. Curr Ther trauma score and the classification and regression tree. Res Clin Exp 2013; 74:16–21. Eye 2010; 24(1): 84–89. 21 Salehi-Had H, Andreoli CM, Andreoli MT, Kloek CE, Mukai S. 10 Feng K, Hu YT, Ma Z. Prognostic indicators for no light Visual outcomes of vitreoretinal surgery in eyes with severe perception after open-globe injury: eye injury vitrectomy study. Am J Ophthalmol 2011; 152(4): 654–662. open-globe injury presentingwith no-light-perception vision. – 11 Agrawal R, Ho SW, Teoh S. Pre-operative variables affecting Graefes Arch Clin Exp Ophthalmol 2009; 247(4): 477 483. final vision outcome with a critical review of ocular trauma 22 Boldt HC, Pulido JS, Blodi CF, Folk JC, Weingeist TA. Rural – classification for posterior open globe (zone III) injury. Indian endophthalmitis. Ophthalmology 1989; 96(12): 1722 1726. J Ophthalmol 2013; 61(10): 541–545. 23 Thompson WS, Rubsamen PE, Flynn Jr HW, Schiffman J, 12 Kim JH, Yang SJ, Kim DS, Kim JG, Yoon YH. Fourteen-year Cousins SW. Endophthalmitis after penetrating trauma. Risk review of open globe injuries in an urban Korean population. factors and visual acuity outcomes. Ophthalmology 1995; 102 J Trauma 2007; 62(3): 746–749. (11): 1696–1701. 13 Soni NG, Bauza AM, Son JH, Langer PD, Zarbin MA, Bhagat N. 24 Dehghani AR, Rezaei L, Salam H, Mohammadi Z, Mahboubi M. Open globe ocular trauma: functional outcome of eyes with Post traumatic endophthalmitis: incidence and risk factors. no light perception at initial presentation. Retina 2013; 33(2): Glob J Health Sci 2014; 6(6): 68–72. 380–386. 25 Lee CH, Lee L, Kao LY, Lin KK, Yang ML. Prognostic 14 Emami-Naeini P, Ragam A, Bauza AM, Soni N, Langer P, indicators of open globe injuries in children. Am J Emerg Med Zarbin MA et al. Characteristics, outcomes, and prognostic 2009; 27(5): 530–535.

Eye